CASE REPORT
A 69-year-old male patient sought care in a cardiology emergency room
for dyspnea, orthopnea and progressive edema of the lower limbs in the
last months, with worsening of the condition. His pathological history
revealed hypertension, ex-smoker (125 pack years), congestive heart
failure and AMI about 1 month ago.
The patient was taking enalapril, bisoprolol, furosemide and
rosuvastine. Upon physical examination on admission, he was in regular
general condition, pale, anicteric and acyanotic. Physiological breath
sounds with fine bilateral bursts audible in bases and middle third.
Dyspneic, with 98% O2 saturation in room air, not able
to lie down. In the evaluation of cardiovascular system, regular heart
sounds (S1, S2), without murmurs. Well-perfused ends.
Laboratory tests, electrocardiogram, transthoracic echocardiogram and
cinecoronarioangiography (due to the history of AMI) were requested. The
exams revealed hemoglobin 11.8 g/dl, hematocrit 37.0%, platelets
306,000, INR (International Normalized Ratio) 1.20 and troponin 0.02.
Admission electrocardiogram shows regular sinus rhythm with pathological
Q waves in the inferior wall.
Transthoracic echocardiogram revealed significant left ventricular
systolic dysfunction, with an ejection fraction of 31%. In addition, an
extensive pseudoaneurysm involving the apical region, measuring 96x116
mm with neck measuring 35 mm, associated with a diffuse moderate-sized
pericardial effusion, with its largest layer measuring 16 mm, adjacent
to the right cardiac cavities, with incipient signs of hemodynamic
repercussion.
As an urgent matter for coronary evaluation, it was decided to perform
cinecoronarioangiography. A right coronary flow pattern was described,
as well as a 40% calcified lesion in the proximal third of the right
coronary. The anterior descendant exhibits marked 40% calcification of
the proximal third with a 50% segmental lesion in the middle third.
Circumflex artery had severe atheromatosis in its proximal third and
occlusion in the middle third.
The patient was referred to the operating room, where the left common
femoral artery was dissected and the right femoral vein was punctured.
Heparinization and cannulation of these vessels were performed. In
cardiopulmonary bypass, due to the risk of rupture, a hypothesis
suggested by the presence of pericardial effusion on the preoperative
echocardiogram, a median transsternal thoracotomy was performed, and the
right great saphenous vein was dissected. In the intraoperative period,
an important ventricular pseudoaneurysm was seen, however, there was no
evidence of the pericardial effusion described on preoperative
echocardiogram (Figure 1)
The pseudoaneurysm was approached through a circular incision bordering
the normal wall. The cavity was disproportionate to the size of the left
ventricle. Cerclage of the edge with fibrotic aspect was performed to
reduce the orifice (Figure 2). The orifice, anchored in felt strips, was
sutured with 16 stitches using polypropylene 3-0, followed by
implantation of bovine pericardium with 3 layers. Finally, a linear
suture was performed on the remaining tissue for better hemostatic
control (Figure 3).